VT/VF During Primary PCI

Bulent Gorenek MD FACC FESC

Eskişehir Osmangazi University Cardiology Department

Eskisehir-Turkey

A variety of arrhythmias and conduction disturbances may occur; as sign of reperfusion, as complication of the intervention or as complication of acute MI in patients undergoing primary PCI

Serious ventricular arrhythmias have been reported up to occur in 5% of the patients undergoing PCI, and in 30% of the patients undergoing primary PCI

Gorenek J Electrocardiol 2006

The risk of ventricular arrhythmias from intracoronary dye is greater with the injection of ionic (high osmolar) contrast agents into the right coronary artery, particularly in the setting of prolonged injection or a damped pressure tracing VF may occur if dye is allowed to remain static in the coronary tree

Role of contrast agents

Sustained VT and VF, Risk Factors and Predictors

Gorenek et al, Acute Cardiac Care, 2007

Nonionic agents in diagnostic coronary angiography may be associated with an increased risk of sustained ventricular arrhythmias

Nonionic contrast agents should be prefered during acute MI, especially in high risk patients to decrease the risk of serious ventricular arrhythmias

Hajj-Ali et al, Am J Cardiol, 2001 (TCT abstracts)

VF may occur with guide catheter wedging or prolonged balloon inflations

Gorenek et al, Acute Cardiac Care, 2007

Killip classification predicts the incidence of arrhythmias in patients undergoing PCI for acute MI

De Geare et al ,Am J Cardiol, 2001

Presence of Heart Failure

In patients with small caliber of RCA associated ST segment changes, the risk of VF was higher during PCI

Huang et al, Int J Cardiol, 2002

Importance of Vessel Diameter

Increased QTC dispersion may predict the risk for lethal ventricular arrhythmias during PCI The fact that successful angioplasty decreased QTC dispersion indicates that a part of increased QTC dispersion is related to myocardial ischemia in patients with coronary artery disease

Ashikaga et al, J Am Coll Cardiol,1998

QT Dispersion

Primary PCI reduces the prevelance of LP more than thorombolytic agents do.The reduction is more prounced in rescue PCI

Karam C et al, J Am Coll Cardiol, 1996

Late Potantials in SAECG & PCI

Characteristics of the patients who had VF before PCI and during PCI

Infarct location was a major determinant of timing of VF, anterior infarction had greater risk for VF before PCI

Henriques et al, Int J Cardiol, 2005

Infarct Location

Mehta RH et al, JAMA, 2009

TIMI Flow and ST Resolution

Infarct Size

Patients developing VF during PCI were more likely to have a history of hypertension and DM

Addala et al, Am J Cardiol, 2005

Hypertension&Diabetes Mellitus

Mehta et al, Am Coll Cardiol, 2004

Independent Risk Predictors

Smoking, lock of beta blocker administration in ER, RCA as IRA, presence of initial TIMI grade O flow and timing of PCI were the independent risks for VT/VF during PCI

Mehta et al, Am Coll Cardiol, 2004

The frequency of VT/VF increases as the time from symptom onset to ER arrival decreases

Time from symptom onset to ER arrival and frequency of VT/VF

The frequency of VT/VF increases as the number of risk predictors increases

Mehta et al, Am Coll Cardiol, 2004

Increasing number of risk factors and the incidence of VT/VF

The incidence of VT/VF and mortality increased as patients' baseline risk increased

Am Heart J 2011;161:782-9

Yoshida et al, Circulation, 2000

Arrhythmia Type DP(n=23) Non-DP(n=38) p

PVC≥1 bpm 9(39.1%) 14(36.8%) 0.86

AIVR/VT 0 7/3(26.3%) <0.01

VF 0 2(5.3%) 0.52

Administration of dipyridamole, increasing interstitial myocardial concentration of adenosine, can prevent and terminate reperfusion arrhythmias such as AIVR and VT in patients undergoing primary PCI

Adenosine has been shown to suppress reperfusion injury and to terminate VT caused by intracellular calcium overload

Lerman BB,et al. Circulation ,1993

Prophylactic Strategies

Intra-coronary enalaprilat infusion in the infarct related artery is feasible in the setting of primary angioplasty which is safe and well tolerated

Effective cardiac ACE inhibition can be achieved by low-dose intracoronary enalaprilat, which primarily causes a potentiation of bradykinin

Kurz et al, Am J Cardiol, 2001

RAS inhibition may decrease reperfusion arrhythmias

Losartan attenuates myocardial ischemia-induced ventricular arrhythmias and reperfusion injury in hypertensive rats

Lee et al, Am J Hypertens, 1997

Pre-PCI beta blocker use was associated with decreased arrhythmia and mortality, without increasing rates of cardiogenic shock and heart failure

Am J Cardiol 2013;111:1714e1720

Antiarrhythmic Effect of Repeated Coronary Occlusion During Balloon Angioplasty

A preceding, short vessel occlusion-reperfusion cycle seems to increase the electrical stability of ischemic myocardium

Airaksinen et al, J Am Coll Cardiol, 1997

RR interval

(ms)

RR interval

(ms)

Blood pressure

(mmHg)

Blood pressure

(mmHg)

Second occlusion

Ventricular ectopy First occlusion

No ventricular ectopy

In high risk patients prophylactic use of IABC may decrease the incidence of VF, especially in patients with cardiogenic shock

Brodie et al, Am J Cardiol, 1999

No IABC or

IABC IABC

Pre intervention Post intervention All Patients p

Cardiogenic shock 12.9% 29.8% 21.0% 0.02 (n=119)

CHF or low EF(≤30%) 0% 5.8% 5. 0% 0.32 (n=119)

All high risk patient 10.3% 14.4% 13. 0% 0.38 (n=238)

Management

Ventricular arrhythmias usually terminate without any intervention Sustained VT associated with hemodynamic compromise, or VF should be treated with synchronized electrical cardioversion/defibrillation No drug therapy is recommended, unless arrhythmias remain after PCI

Gorenek et al, J Electrocardiol, 2006

Outcomes of VT/VF

Mehta RH et al, JAMA, 2009

Early (≤48 hours), late ( >48 hours) after their symptom onset

Sustained VT/VF after PCI in the HORIZONS-AMI trial was not significantly associated with 3-year mortality or major adverse clinical events

Am J Cardiol 2012;109:805–812

Arrhythmias may occur either as complication of intervention or as complication of acute MI in patients undergoing primary PCI However, in many cases VT/VF are the predictors of successful reperfusion Generally, they tend to revert spontaneously, but when necessary, electrical cardioversion/defibrillation should be applied promptly

VT/VF during primary PCI do not influence PCI success. The extremely short time to defibrillation and easy access to other emergency equipment likely explain this

Long term outcomes are not affected by these arrhythmias

Conclusions

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